Nurse Navigation in the Torres and Cape – “Unique Population = Unique Model of Care”

Mrs Rachel Sargeant1, Ms Michelle Maguire2, Mrs Natalie Thaiday3

1Torres And Cape Hospital And Health Service, Cairns, Australia,

2Torres and Cape Hospital and Health Service, Cairns, Australia,

3Torres and Cape Hospital and Health Service, Cairns, Australia


Coordination of complex care provision across Torres and Cape Hospital Health Service (TCHHS) has been historically challenging due to its geographical area and diverse population group. The TCHHS is approximately 130 336 Sq. km with 89% of the population identifying as Aboriginal or Torres Strait Islander. There are over 28 indigenous clan groups with 18 different languages spoken with English often the second language. The challenges when trying to access health services include:

–              Poor communication systems

–              Limited health literacy/health services

–              Poor local infrastructure, limited housing

–              Climate e.g. cyclones, flooding

–              Dirt roads, limited flights (dinghy is sometimes only means of transport).

The Nurse Navigation initiative uses a multi-disciplinary, holistic approach to facilitate patient-centered care, improve health systems by being the central point of communication, engagement and coordination of services in the patient’s journey. The service aims to deliver respectful culturally safe care.  TCHHS is the first in Queensland to have generated the Indigenous Nurse Navigator Support Officer roles. This model of care has positively impacted on the population by building relationships with patients and families, increasing health services access and demonstrate a significant financial saving to the health system.

The benefits of implementing Nurse Navigation in the vast area of the Torres and Cape are outstanding and extensive. They include but are not limited to:

–              Decreasing complexity of health systems for clients

–              Improving health literacy

–              Advocating for the client

–              Half a million dollars in savings to TCHHS in first year of service delivery

–              Increasing appointment attendance and decreasing hospital readmissions

A single point of communication and coordination such as Nurse Navigation services, links care providers and delivers improved patient care outcomes. The Indigenous Nurse Navigator Support Officer expands the impact of this service further empowering the clients in this service.


There are ten Nurse Navigators, one Nurse Navigator project officer and two Indigenous Nurse Navigator Support Officers within the Torres and Cape Hospital Nurse Navigator Service. All Nurse Navigator positions are Clinical Nurse Consultant level, delivering generalist care. The Indigenous Nurse Navigator Support Officer based in Cairns is an Enrolled Nurse currently undergoing undergraduate studies for Bachelor of Nursing.  Nurse Navigation role supports clients with complex care needs, facilitates specialist appointments, coordinates appointments, telehealth and referrals. Improving access and engagement of clients and families with health service and providers in and out of community.